Two major policy approaches are used currently to motivate hospitals to prevent hospital-acquired complications (HACs): 1) public reporting of hospital performance regarding patient safety (e.g., the website Hospital Compare), and 2) value-based purchasing, which ties hospital payment with better patient outcomes, such as the Hospital-Acquired Conditions Initiative implemented by the Centers for Medicare & Medicaid Services (CMS) to stop hospitals from receiving extra payment for specific reasonably preventable complications. This CMS initiative also enables public reporting of HACs by requiring hospitals to identify discharge diagnoses as present-on-admission or not (i.e., hospital-acquired), changing a routinely-generated administrative dataset into a new data source to generate rates of HACs to compare hospitals. Though intended to improve patient safety (and save money), these changes regarding data collection, payment, and public reporting of HACs have occurred without preliminary evaluations concerning: 1) the validity of these new data regarding HAC rates, and 2) what clinical impacts these changes may have on patients. These two knowledge gaps are significant, as public reporting of other patient outcomes (e.g., hospital mortality) has demonstrated that evaluating and reporting outcome data is complicated, and can have both intended and unintended consequences for patients - particularly for complex patients (i.e., with multiple chronic conditions) with higher baseline risks for poor outcomes including HACs. The candidate Dr. Jennifer Meddings, who will focus her research on the growing population of complex patients, will pursue a mentored research plan designed to enhance her skills concerning methods needed to evaluate the clinical impact of quality improvement initiatives for complex patients, with two specific aims: Aim 1. To validate measures of hospital-acquired complications derived from administrative data as indicators of hospital quality, by triangulation with measures from different data sources. Aim 2. To evaluate unintended outcomes (i.e., collateral benefits and damages) for patients as downstream or spillover effects of non-payment and public reporting for specific hospital-acquired complications, with a focus on impacts for complex patients. Using multiple years of patient-level administrative data, Aim 2's analyses will focus on three outcomes that could improve (as collateral benefit) or worsen (as collateral damage) as hospitals respond to non-payment or public reporting for specific HACs: 1) early readmission, 2) level of care after discharge (such skilled nursing facility), and 3) secondary complications, related to developing or treating the initial HAC. This research and advanced coursework will facilitate Dr. Meddings's development into a leading independent investigator in performance measurement and improvement, whose research will inform policy decisions to improve care for complex patients. PUBLIC HEALTH RELEVANCE: As the elderly population increases, the number of complex patients (i.e., with multiple chronic diseases) is rising dramatically. Because complex patients have higher rates of hospitalizations, with longer lengths of stay and higher rates of hospital-acquired complications, complex patients are perhaps the most important population to assess and monitor the impact of two quality improvement strategies being used to motivate hospitals to decrease hospital-acquired complications: 1) public reporting of hospital performance regarding patient safety (such as the website Hospital Compare), and 2) value-based purchasing, which ties hospital payment with better outcomes, such as the recently implemented Hospital-Acquired Conditions Initiative by the Centers for Medicare & Medicaid Services (CMS) to stop hospitals from receiving extra payment to treat specific reasonably preventable hospital-acquired complications. The proposed research will assess the merit of the new data for complication rates as indicators of hospital quality, and will assess the clinical impacts (intended and unintended) of value-based purchasing and public reporting initiatives for complex patients; this research will provide critical early feedback to the public, clinicians, hospitals, and CMS to reduce unintended harm to complex patients as well as to inform approaches for developing and evaluating future healthcare reforms designed to motivate improved care.